The utility of sonographic signs to diagnose simple and complicated appendicitis in children.

BACKGROUND: Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children. METHODS: Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant). RESULTS: A total of 934 USS were included, with median age 10.7 [8.0-13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90-0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57-0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004). CONCLUSION: Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children.

Stratifying features for diagnosing hypertrophic stenosis on ultrasound: a diagnostic accuracy study.

BACKGROUND: Our aims were to determine if the diagnostic threshold for diagnosing hypertrophic pyloric stenosis (HPS) on ultrasound scan (USS) should be adjusted based on birth weight (BW), current weight (CW), gestational age (GA), chronological age (CA) or corrected gestational age (CGA). METHODS: All patients who underwent either an USS and pyloromyotomy (Group 1) or an USS for possible HPS (Group 2) at our tertiary centre between July 2013 and June 2019 were identified. Ideal threshold values are identified by measuring Youden's Index (J = sensitivity + specificity - 1; higher is better). Mean maximum Youden's Index for stratified results was compared to that for combined results. RESULTS: Two hundred and eighty-four patients were included (142 patients in both Group 1 and Group 2). Combined maximum Youden's Index for all patients was 0.92 for pyloric canal thickness (PMT) and 0.87 for pyloric canal length (PCL). Mean maximum Youden's Index was higher when patients were stratified by GA, CGA, BW or CW, and equivalent for CA. For pyloric canal length (PCL), mean maximum Youden's Index was lower for all variables when stratified compared to combined. There was no visual trend observed in the diagnostic thresholds between groups. CONCLUSION: Stratifying USS PMT diagnostic thresholds values based on age and weight is statistically more accurate than a single threshold in diagnosing HPS. However, the lack of visual correlation indicates a larger dataset is required to validate these results.

Clinical data and Pediatric Quality of Life Inventory (PedsQL™) scores for children with duodenal atresia.

This article presents raw data obtained from a prospectively collected database of children with duodenal atresia at tertiary pediatric surgery hospital. For all potential participants, pertinent demographic, clinical and operative data was obtained from the database. Potential participants were then contacted and invited to complete a Pediatric Quality of Life Inventory (PedsQL™) 4.0 core score and gastrointestinal module questionnaires. Participant's response to each item in the questionnaires is provided, as well as their calculated health related quality of life scores. Data has the potential to be reused in future studies examining quality of life in duodenal atresia, paediatric gastrointestinal conditions, surgical neonatal conditions and children with trisomy 21. Further analysis and discussion is contained in related research article titled "Quality of life outcomes in children born with duodenal atresia" [1].

Presentation and outcomes in hypertrophic pyloric stenosis: An 11-year review.

AIM: To evaluate the trend in presentation and postoperative outcomes of infants with hypertrophic pyloric stenosis (HPS) over the last decade. METHODS: This was a multicentre retrospective study in two tertiary paediatric centres between 2005 and 2015 inclusive. Participants included 626 infants who underwent a pyloromyotomy for HPS. We collected data on presentation features (age, weight, clinical signs, blood gas results, ultrasound findings) and postoperative outcomes (length of stay (LOS), complications, time to first postoperative feed). RESULTS: No trend was identified during the study period with regards to age, weight, biochemical findings (pH, chloride, base excess) or pre-operative ultrasound measurements. There was a downtrend in the number of palpated tumours over time, with a mean of 36% of tumours clinically palpated. Pyloric wall thickness had a moderate association with LOS in patients admitted for >8 days (correlation = 0.4752) but had a weak negative association with shorter lengths of stay (≤8 day, correlation = -0.094). Overall, median time to first feed was 7.80 h and improved yearly during the study period (hazard ratio = 1.07). CONCLUSIONS: Patients presenting with HPS are not being identified at an earlier age or with fewer biochemical derangements, in contrast to our initial perceptions. Subsequently, biochemical derangements can still play an important role in the diagnosis of HPS, and attention needs to be given to fluid management and electrolyte correction in all patients with HPS.

Studying the Thenar Eminence of Amateur cooKs (STEAK) study: a double-blinded, cross-sectional study.

OBJECTIVES: To evaluate the reliability of using the thenar eminence to determine steak doneness. DESIGN: Double-blinded, cross-sectional study. SETTING: Various home kitchens in Melbourne, Australia. PARTICIPANTS: Amateur/home cooks. MAIN OUTCOME MEASURES: The accuracy of the finger test (the tenseness of the thenar eminence in different hand positions) for determining how well a random beef steak has been cooked (rare v medium-rare v medium v well-done). We also examined whether participants improved with practice and whether the accuracy of the finger test was correlated with age, sex, cooking experience or self-rated steak-cooking ability. RESULTS: Twenty-six participants completed the study, and showed that they could accurately determine the doneness of a steak with the finger test better than chance (χ2[1, n = 156] = 9.88; P < 0.01). Their overall accuracy, however, was low (36%). There was no correlation between accuracy in application of the finger test with the other collected participant and steak variables. CONCLUSIONS: The finger test can be used by amateur cooks to determine beef steak doneness. However, the low overall accuracy of the test suggests that more invasive tests are to be recommended for determining steak doneness for its health benefits.

Comparison of local anesthetics for digital nerve blocks: a systematic review.

PURPOSE: To evaluate the time to onset of anesthesia, duration of anesthesia, and pain on injection of local anesthetics. METHODS: A systematic search of the English literature was performed of the Medline, Cochrane Central Register of Controlled Trials, The Allied and Complementary Medicine Database (AMED), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, and 6 articles were complied with the study inclusion criteria. RESULTS: Six studies (335 nerve blocks) were included in our final analysis measuring 6 local anesthetic preparations (lidocaine, lidocaine with epinephrine, bupivacaine, bupivacaine with epinephrine, lidocaine with bupivacaine, and ropivacaine). Lidocaine demonstrated the shortest mean onset of anesthesia (3.1 min) and bupivacaine the longest (7.6 min). Lidocaine also demonstrated the shortest mean duration of anesthesia (1.8 h) and ropivacaine the longest mean duration (21.5 h). Lidocaine with epinephrine demonstrated the least mean pain on injection (26 mm on a visual analog scale) and bupivacaine with epinephrine the most mean pain (53 mm). CONCLUSIONS: Lidocaine with epinephrine provides a good short-term anesthesia and may reduce the risk of injury or complication while the finger in still anesthetized. Bupivacaine with lidocaine provides good long-term anesthesia and may reduce the need for postprocedural anesthesia. Ropivacaine likely provides the longest duration of anesthesia but the absence of epinephrine means a tourniquet must be used to create a bloodless field and thus is contraindicated in some procedures such as flexor tendon repairs where active testing may be required. CLINICAL RELEVANCE: Lidocaine with epinephrine, bupivacaine with epinephrine, and ropivacaine all provide benefits in digital nerve blocks. The surgeon may choose the most appropriate local anesthetic or combination of local anesthetics based on the procedure to be undertaken and the postoperative requirements. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.